Valvular heart disease Flashcards
Epidemiology of valvular heart disease (4)
Degenerative valve disease
- reflects ageing population
Rheumatic valve disease
- post strep rheumatic fever
- children and young adults
- disease of poverty and overpopulation
Infective
- Most common on abnormal valves
- immunocompromised
Congenital valve disease
- low, static incidence in all populations
Aetiology of valvular heart disease (5)
Degenerative: aortic > mitral
Rheumatic: mitral > aortic
Infective: any valve, right from IVDU
Secondary to loss of supporting structure
Congenital: any valve
Pathology
Fibrosis: fusion of leaflets
Calcification: immobility of leaflets
Dilation: of valve ring
Stenosis
Narrowing of valve leaflets
Valve leaflets fail to open completely
Leads to build of back pressure and loss of stroke volume
Regurgitation
Failure of leaflets to meet in systole
Leaflets fail to close completely
Allows reverse flow of blood during relaxation of the heart
Aortic stenosis age of presentation
Congenital (paediatrics, <60)
Bicuspid (40-60 years)
Degenerative (>60)
Post rheumatic fever (<60)
Aortic stenosis features
Obstruction to flow
- severe: chest pain, syncope, shortness of breath, fatigue, palpitations
- early: no symptoms
Pressure overload
- high LV pressure
- LV hypertrophy
- eventual LV decompensation/ dilation
Aortic stenosis heart sounds
Systolic crescendo/ decrescendo murmur
- doesn’t open so turbulent flow of blood
- pressure rises in systole, peaks then falls
Soft second heart sound
- valve is stiff and thickened so doesn’t close properly
Aortic stenosis symptoms
SAD triad: syncope, angina, dyspnoea
Fatigue: decrease in exercise tolerance
Sudden death: rare in asymptomatic, significant risk in symptomatic
Arrhythmias due to pressure overload
Aortic regurgitation aetiology
Aortic dilation - loss of support - connective tissue disease - hypertension aortic dissection, degenerative, cystic medial necrosis, syphilis Valvular - bicuspid - endocarditis
Aortic regurgitation consequences
Volume overload: blood falls back into LV during diastole
LV dilation: to acommodate volume, typical result of volume overload
Late decompensation of LV function
High volume circulation: as in pregnancy, anaemia, thyrotoxicosis
Aortic regurgitation heart sounds
Early diastolic murmur
- valve leaflets fail to come together
- blood under high pressure in aorta rushes back into the ventricle
- pressure in ventricle lowest at beginning of diastole
Concomitant systolic murur
- aortic valve often structurally abnormal
- turbulence as blood exits ventricle during systole
Aortic regurgitation symptoms
Often asymptomatic Chest pain Breathlessness Syncope- uncommon Catastrophic decompensation if acute fulminant pulmonary oedema
Mitral regurgitation aetiology
Valvular: prolapse, infective, degenerative
Chordal rupture/ papillary muscle failure- acute/ chronic
Annular dilation: secondary to left ventricle dilation
Mitral regurgitation consequences
Volume overload in left ventricle: during systole blood ejected back to LA, extra blood in LA means elevation of pressure ao increased LV filling in diastole
Pressure overload of right heart: RV hypertrophy or right heart failure
Left ventricular dilation: response to volume overload
Decompensation: pulmonary oedema
Mitral regurgitation heart sounds
Pan-systolic murmur:
- leaflets fail to coapt
- blood leaks back to LA with turbulence
- occurs for whole of sytsole
Mitral regurgitation symtpoms
Breathlessness due to back pressure of pulmonary circulation Lethargy and reduced exercise tolerance Palpitations Peripheral oedema Chest pain
Mitral valve prolapse
Leaflet is too baggy or abnormal valvular apparatus
Leaflet prolapses back into LA
Allows through jet of regurgitation
Mitral valve prolapse heart sounds
Mid systolic click:
- leaflets prolapse back into the LA
Late systolic murmur:
- blood continues to flow into LA after initial jet of regurgitation
Mitral stenosis aetiology (7)
- almost always due to rheumatic fever
- congenital
- storage disease
- malignancy
- previous endocarditis
- mitral valve calcification
- systemic disease
Mitral stenosis consequences
Lung/ right heart consequences:
- breathlessness, congestion
- due to pressure back up because of failure of ejection of left atrial volume
Left ventricle physiology usually preserved
- LV function compromised when atrial contraction lost or high circulating volume
Mitral stenosis heart sounds
Mid diastolic rumbling
- stenosis restricts blood flowing across mitral valve from LA to LV
Opening snap
- as the restricted leaflets snap open
Loud first heart sounds
- leaflets are stiff but still relatively mobile
- leaflets slam shut
Mitral stenosis symptoms
Lungs: breathlessness, peripheral oedema, haemoptysis Palpitations Systemic emboli Fatigue Compressive symptoms: stridor, dysphagia
Trans-cutaneous valve replacement
Aortic: new technology, patients considered high risk for AVR, procedures under local anaesthetic , shorter recovery time
Mitral valve: mitraclip
